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The nurse reviews the physical assessment and vital signs to determine the initial care needs of the client.

Click to highlight the findings that require follow-up by the nurse. Select all that apply.

Bilateral finger clubbing

Temperature: 100.2° F (37.9" C)

Poor oral hygiene

Heart sounds of S1, S2, S3, Sa

Generalized weakness and easily fatigued

Intercostal retractions

Respiration: 38 breaths/minute

Increased thirst

Pain: rated 6 on a 0 to 10 scale, heaviness in the chest

Oxygen saturation: 87% on 2 liters/minute via nasal cannula

Answer and Explanation

Correct Answer : D,F,G,I,J

A. Bilateral finger clubbing: Finger clubbing is a chronic change often associated with long-standing hypoxia or pulmonary disease. While it is abnormal, it represents a long-term adaptation and does not require immediate intervention.

B. Temperature: 100.2° F (37.9° C): Mild fever is noted, but this level is not immediately life-threatening and can be monitored as part of ongoing assessment.

C. Poor oral hygiene: Poor oral hygiene is important for overall health but does not represent an urgent clinical issue in the current emergency presentation.

D. Heart sounds of S1, S2, S3, S4: The presence of S3 and S4 heart sounds along with a systolic murmur suggests possible acute decompensated heart failure, which requires immediate follow-up and intervention to prevent further cardiovascular compromise.

E. Generalized weakness and easily fatigued: While significant for overall functional status, this is expected in clients with chronic illness and is not an immediate threat requiring urgent intervention.

F. Intercostal retractions: Retractions indicate significant respiratory distress and increased work of breathing, necessitating prompt assessment and intervention to prevent respiratory failure.

G. Respiration: 38 breaths/minute: Tachypnea signals respiratory compromise and requires urgent monitoring and potential intervention to improve oxygenation.

H. Increased thirst: This may indicate fluid imbalance or hyperglycemia but is not immediately life-threatening and can be addressed after urgent issues are managed.

I. Pain: rated 6 on a 0 to 10 scale, heaviness in the chest: Chest heaviness may indicate cardiac ischemia or pulmonary compromise. Immediate assessment is required to rule out acute coronary syndrome or other emergent conditions.

J. Oxygen saturation: 87% on 2 liters/minute via nasal cannula: Hypoxemia is a critical finding indicating insufficient oxygenation. The nurse must intervene immediately to optimize oxygen delivery and address underlying respiratory compromise.

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Correct Answer is D

Explanation

A. Palpate for abdominal distention: While monitoring for abdominal distention is part of ongoing assessment, it does not directly address the immediate observation of slow drainage after paracentesis. Palpation alone will not ensure safe fluid removal or detect complications from the drainage.

B. Send fluid to the laboratory for analysis: Fluid collected during paracentesis is typically sent for laboratory analysis to identify infection or other abnormalities, but the drainage described in this scenario is already in progress, and sending it to the lab does not address the priority of monitoring ongoing output.

C. Clamp drainage tube for 5 minutes: Clamping the drainage tube unnecessarily can disrupt the drainage process and may cause fluid accumulation or increased intra-abdominal pressure. This action is not indicated unless ordered for a specific clinical reason.

D. Continue to monitor the fluid output: Monitoring the output is the priority nursing action because the slow drainage may indicate that the fluid is draining appropriately or that there is a problem with the tubing or client positioning. Continuous observation ensures timely detection of complications such as hypotension, rapid fluid shifts, or infection and guides further interventions.

A. Pain rating of 8 on a scale of 0 to 10. B. High-pitched sound heard upon inspiration. C. Redness and edema noted at the incision site. D. Apical heart rate of 100 to 110 beats/minute.

Correct Answer is B

Explanation

A. Pain rating of 8 on a scale of 0 to 10: Postoperative pain is expected after an appendectomy. While high pain warrants management, it is not immediately life-threatening.

B. High-pitched sound heard upon inspiration: This finding suggests potential airway compromise, such as stridor, which can indicate laryngeal edema or obstruction. Immediate assessment and intervention are required to maintain airway patency.

C. Redness and edema noted at the incision site: Mild redness and edema are common in the early postoperative period and should be monitored, but they do not constitute an immediate emergency.

D. Apical heart rate of 100 to 110 beats/minute: Mild tachycardia is a common response to pain, stress, or anesthesia and should be monitored, but it is not immediately life-threatening.

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The nurse reviews the physical assessment and vital signs to determine the initial care needs of the client. Click to highlight the findings that require follow-up by the nurse. Select all that apply.

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Naxlex Comprehensive Predictor Exams

During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 mL of clear, straw-colored fluid drains within the first hour. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Correct Answer is B

Explanation

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The nurse reviews the physical assessment and vital signs to determine the initial care needs of the client.

Click to highlight the findings that require follow-up by the nurse. Select all that apply.